Provider Demographics
NPI:1205470333
Name:KOCHUPURACKAL, LISSY MATHEW
Entity type:Individual
Prefix:
First Name:LISSY
Middle Name:MATHEW
Last Name:KOCHUPURACKAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8141 249TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-2517
Mailing Address - Country:US
Mailing Address - Phone:917-601-3543
Mailing Address - Fax:
Practice Address - Street 1:7403 COMMONWEALTH BLVD
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-1839
Practice Address - Country:US
Practice Address - Phone:917-601-3543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0714671163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent